MacKenzie-Udoji Insurance Agency :: Request a Certificate of Insurance

Request a Certificate of Insurance

This page is intended for contractors only. If you are looking for assistance with any other business or personal insurance needs, please contact us. To request a commercial Certificate of Insurance, please fill out the following form:

Date

Insured's Name

Email Address

REQUIRED

Name of Certificate Holder

771 Adams Street

Dorchester MA 02122

Job Name/Property Name

Location Address

Special Requirements

Yes No

Certificate Holder
"Named Additional Insured"

(ISO Form CO 20 10 11 85)

	30 Day Notice of Cancellation
	10 Day Notice of Cancellation
	Special Wording for Banks: Their Successors and/or Assigns, ATIMA
	ISO Form CG 25 03 11 85 Separate Aggregate Limit per Project

Additional Requirements

Special Forms to Attach

Additional Comments